Employee Healthcare Forms & Information

All of our forms are in PDF format, so you will need to download and install Adobe Acrobat® if you have not already done so.

_Link: _{2012 EMPLOYEE BENEFIT PLANS INFORMATION}

Benefit Handbooks

Employee Benefits Handbook - PDF
Employee Benefits Handbook DJFS-AFSCME Members - PDF

Medical

Dental

DCP Benefit Outline Summary - PDF

DCP Covered Services - PDF

Vision

Flexible Spending Acct(FSA)

FSA Basic Plan Information - PDF
Dependent Care FSA Info - PDF
FSA Reimbursement Request Form - PDF
FSA Debit Card Substantiation Form - PDF
FSA - Qualifying Event Change Form - PDF

Life, LTD & STD Insurance

County Paid Life and AD&D Insurance Policy - PDF

County Paid Life and AD&D Insurance Policy - Elected Officials - PDF
Long-Term Disability Insurance Policy - PDF
Voluntary Term Life Insurance Policy - PDF
Voluntary Term Life Insurance Policy - Elected Officials - PDF
Waiver of Premium Form - PDF
Application for Accidental Death Benefits - PDF
Living Benefit Form - PDF
Term Life Portability Request Form - PDF
Conversion Application - PDF
Voluntary STD-LTD – Cancellation Form - PDF
Voluntary STD-LTD Disability Claim Form - PDF
Short Term-Long Term Insurance – Voluntary Coverage - PDF

COBRA

Initial COBRA Notification Document - PDF
The Basics of COBRA - PDF
COBRA – Employer Notification Form - PDF
COBRA Rates - PDF

Miscellaneous

What is CONCERN Services? - PDF
HIPAA Privacy Notice - PDF